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Deficiency Form (15) DHR-DFC-1926 ALABA A DEPARTMENT OF HUMAN RI URCES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT SECTION A - IDENTIFYING INFORMATION Facility Name: Type of Facility: Home Date of Visit: FUN 4 KIDZ Day ® Group ❑ �� Night ❑ Center ❑ '5 Day/Night ❑ S.A.P ❑ month / day / year Facility Address: Licensee: Telephone#: 305 W COURTLAND AVE MELISSA GORMAN (256)248-4949 MUSCLE SHOALS, AL 35661 Ages: Director(if ap li ble): Capacity: 1 Weeks through 5 Years 6 - Day SECTION B - DEFICIENCY INFORMATION Column 1 Column 2 Minimum Standard Date Corrected by Deficiency Licensee t zz 00, INSTRUCTIO S TO L CENSEE: Column 2, Date Corrected by Licens e, is to be co eted by the facility representative after each deficiency is corrected. The facility representative must put the date of correction nd hi er initials in Column 2. This form must be returned to the Department of Human Resources on or before 8 , as veriftcaiion that deficiencies have been corrected NOTICE: Any misleading or any false statements or reports made to the Department and/or failure to correct the listed deficiencies can be the basis for adverse action. None of these requirements are to be interpreted to allow anyone to operate in violation of Minimum Standards. A facility licensed by the Department must meet Minimum Standards applicable to that facility at all times. It is the responsibility of the license operate in carliance with Minimum Standards. Signature of Facility Representative Dat Signature of DHR Licensing Representative -Dat r COPIES TO: APR 3 0 «jg Page / of _ DHR-DFC-1927 ALABAMA DEPARTMENT OF HUMAN RESC :CES CHILD CARE MINIMUM STANDARDS DEFICIENCY REPORT (Additional Page) Facility Name: FUN 4 KIDZ Date of Visit: .3 l/ SECTION B - DEFICIENCY INFORMATION (Continued) Column I Column 2 Minimum Standard Date Corrected by Deficiency Licensee 12 IV Wu INSTRUCTIONS TO LICENSEE: Column 2,Date Corrected by Licensee, is to be completed by the facility representative after each deficiency is corrected The facility representative must put the date of correction qnd hiVher initials in Column 2. This form must be returned to the Department of Human Resources on or before JfWlz F as verification that deficiencies have been corrected. NOTICE: Any misleading or any false statements or reports made to the Department and/or failure to correct the listed deficiencies can be the basis for adverse action. None of these requirements are to be interpreted to allow anyone to operate in violation of Minimum Standards. A facility licensed by the Department must meet Minimum Standards applicable to that facility at all times. It is the responsibility of the licensee to operate in comp iance with Minimum Standards./} Signature of Facility Representative r Date Signature of DHR Licensing Representativ Date / COPIES TO: Page =atf C: _